Garden-based Interventions And Early Childhood Health: An .
Skelton et al. International Journal of Behavioral Nutrition and Physical Activity(2020) VIEWOpen AccessGarden-based interventions and earlychildhood health: an umbrella reviewKara R. Skelton* , Chenery Lowe, Daniel A. Zaltz and Sara E. Benjamin-NeelonAbstractBackground: Garden-based interventions show promise for improving not only child nutrition, but other indicatorsof child health. Yet, existing systematic reviews of garden-based interventions often focus on one particular healthoutcome or setting, creating a need to holistically summarize review-level evidence on the role of garden-basedinterventions in early childhood. To fill this gap, we performed an umbrella review of garden-based interventions toexamine their role in early childhood health promotion for children ages 6 years and younger, examining effectivecomponents of garden-based interventions and critically evaluating existing evidence.Methods: We searched the following databases: PubMed, PubMed, PsycINFO, ERIC, CINAHL, Embase, Scopus, OVIDAgricola, and CAB Direct, limiting to reviews published from 1990 to August 2019. Of the 9457 references identified,we included a total of 16 unique reviews for analysis.Results: Across reviews, garden based-interventions were most effective at improving nutrition-related outcomesfor children, including nutritional status and fruit and vegetable consumption. Few reviews examined child healthoutcomes of garden-based interventions that were not nutrition related, such as physical activity, or academicperformance. Across settings, there was the most evidence in support of garden-based interventions conducted inhome gardens, compared to evidence from early care and education or community settings. We were unable toreport on most effective components of garden-based interventions due to limitations of included reviews.Conclusions: Existing evidence is difficult to interpret due to methodological limitations at both the review andprimary study level. Therefore, the lack of evidence for certain child health outcomes should not necessarily beinterpreted as an absence of an effect of garden-based interventions for specific outcomes, but as a product ofthese limitations. Given the breadth of evidence for garden-based interventions to improve a number ofdimensions of health with older children and adult populations, we highlight areas of future research to addressevidence gaps identified in this umbrella review. Further research on the role of garden-based interventions,including their impact on non-nutrition early childhood health outcomes and how effectiveness differs by settingtype is necessary to fully understand their role in early childhood health promotion.PROSPERO registration: CRD42019106848.Keywords: Early childhood, Early years, Child nutrition, Gardens, Preschool, Physical activity, Agriculture* Correspondence: kskelton@towson.eduDepartment of Health, Behavior and Society, Johns Hopkins BloombergSchool of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver ) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.
Skelton et al. International Journal of Behavioral Nutrition and Physical ActivityBackgroundIn recent years, evidence from on the linkage betweenearly childhood behaviors, sustained quality of life, andadult heath has come from the fields of epigenetics, nutrition, physical activity, and neuropsychology [1, 2].This has led global and national organizations toprioritize interventions focusing on early childhoodhealth [3–6]. Epigenetic research exploring the developmental origins of health has found that early childhoodnutrition, in particular, is a vital determinant of adulthealth [1]. Early childhood environmental exposures, including nutrition, influence the gut microbiome andbrain development, which are critical in the maintenanceof a healthy immune response [1] and proper physicaland socioemotional development [7]. With both earlychildhood physical activity and nutrition influencing cardiometabolic health [8], establishing healthy habits inthese behavioral areas in early life quintessential to longterm health promotion [9]. Ultimately, the large numberof habits developed during the first years of life and theimpact early childhood health has on future health,makes it an ideal time for health promotion [9–11].Effective approaches for early childhood health include both macro-and micro-level interventions. On amacro-level, policies and environments can promoteearly childhood health. At a micro-level, innovativestrategies, such as interventions that include multiplecomponents such as experimental learning and education have shown positive health outcomes for youngchildren. These types of interventions may prove keyin health promotion during early childhood. Gardenbased interventions, which typically include hands-onlearning with fruits and vegetables, nutrition education about food origins and systems, and productionof fresh produce, have been associated with improvedchild health outcomes [12–18].Garden-based interventions have demonstrated improvements in nutrition-related indicators, such as childnutritional status and food security, fruit and vegetableconsumption, and weight status [14, 16, 17, 19–22].Additionally, garden-based interventions have been utilized as a form of therapy for specific disorders and diseases, including autism spectrum disorder [23] andchildhood cancer [19]. There may be additional healthbenefits of garden-based interventions, such as socioemotional development or biological health measures. Indeed, improvements in biological measures for children,such as vitamin A status (serum retinol) and iron deficiency anemia have resulted from garden-based interventions [24, 25]. These hands-on interventions mayalso increase outdoor physical activity [26] and improveacademic performance [27]. For older youth and adults,gardens have improved mental health, and may help reduce anxiety, stress, and anger [16, 28, 29].(2020) 17:121Page 2 of 19To date, several reviews have examined the impact ofgarden-based interventions on children and reportedpositive effects for many child health outcomes [15, 19,27, 30–33]. However, the impact of garden-based interventions during early childhood is difficult to collate asfew reviews have assessed multiple child health outcomes in the same article. Most existing reviews focusedon a singular outcome, such as fruit and vegetable intake[30], academic performance [27], or mental health [34].Further, some reviews focused on a single type of gardening program (e.g., farm-to-preschool) [32], ratherthan exploring the multiple settings in which gardenbased interventions can occur. Additionally, most reviews do not singularly focus on early childhood; rather,early childhood outcomes are included as sub analysesof the review. Thus, there is a need to comprehensivelycollate the evidence regarding the impact of gardenbased interventions on a variety of early childhood outcomes. In effort to address this evidence gap, we conducted an umbrella review to summarize existing reviewlevel evidence of garden-based interventions on healthoutcomes for children ages 6 years and younger.MethodsFor this umbrella review, we aimed to 1) identify andsynthesize existing review-level evidence on gardenbased interventions for children ages 6 and younger; 2)examine which components of garden-based interventions are most effective at improving child health outcomes; and 3) critically evaluate included reviews bothnarratively and quantitatively; and 4) identify potentialgaps in the literature and highlight possible areas for improvement in the field of garden-based interventions, including but not limited to study design, measurement,and health outcomes. We used guidance from the Joanna Briggs Institute (JBI) Methodology for UmbrellaReviews [35] and the Cochrane Handbook’s Methodology for conducting an overview of reviews [36] to strategically create an a priori protocol for this umbrellareview [37]. The published protocol for this review wasdeveloped in accordance with the Preferred ReportingItems for Systematic Reviews and Meta-Analyses Protocols (PRSIMA-P) 2015 Statement [38] and registeredwith PROSPERO (International Prospective Register ofSystematic Reviews, CRD42019106848). We used thesystematic review management software Covidence [39]to streamline the review process.Search strategyIn January 2019, we searched PubMed, PsycINFO, ERIC,CINAHL, Embase, Scopus, OVID-Agricola, and CABDirect, restricting to articles published after January1990. We also searched review registries, including theCochrane Register of Systematic Reviews, the JBI
Skelton et al. International Journal of Behavioral Nutrition and Physical ActivityDatabase of Systematic Reviews and Implementation Reports, and PROSPERO. We included the first 200 resultsof Google Scholar, when sorted by relevance. For included articles, we performed forward and backward citation searches to identify any relevant reviews. Prior todata analysis, we conducted an updated search for articles published between January and August 2019.We crafted search terms using synonyms for gardeningand young children used in prior reviews [15, 30, 31, 40],including additional terms created through collaborationwith a medical librarian specializing in systematic reviews.For each database searched, we used database-specific controlled vocabulary and key terms. For databases without advanced search options (e.g., Google Scholar), we used asimpler search strategy that was comprised of a variation ofgardening terms (e.g., “gardening”, “review”, and “children”).A pilot search informed the development of the final searchstrategy, which is located in Additional file 1.Eligibility criteriaWe delineated a priori inclusion and exclusion criteriautilizing the population, intervention, context, outcome,and study design (PICOS) [41]. We applied eligibility criteria at both the systematic review and primary studylevel. For a review to be eligible for inclusion, at least oneprimary study had to meet all inclusion criteria. For example, if a review appeared eligible for inclusion, but further examination revealed no primary studies that metinclusion, we excluded the review.(2020) 17:121Page 3 of 19ContextWe included garden-based interventions occurring in anycountry and setting, including homes, early care and education programs (e.g., preschool or child care), communitycenters or community gardens, afterschool programs, andsummer camps. We included garden-based interventionsthat focused on gardening interventions only, as well asmulti-component interventions that included gardening.OutcomesWe included reviews with at least one of the followingchild-level health outcomes of interest: nutrition-relatedbehaviors (e.g., consumption, attitudes, preferences, dietary quality), nutritional status, anthropometric measures(e.g., body mass index (BMI), body fat percentile, BMI zscore), physical activity, cognition-related outcomes (e.g.,academic performance, developmental milestones), mentalhealth (e.g., social behavior, stress, anxiety), screen time,and biological outcomes (e.g., hemoglobin, serum retinol,microbiome). We excluded reviews that did not report onat least one of the child health outcomes of interest forour population of interest. We considered adverse or unintended consequences when noted in reviews. Althoughwe included reviews that reported on both child andparent-level health outcomes, we extracted only childlevel outcomes for our population of interest for analysis.We excluded reviews that included only parent-, school-,or community-related outcomes. We extracted health outcomes for our population of interest only. In instancesthat a review included multiple health outcomes of interest, but we could not disaggregate outcomes for our population of interest, we excluded that outcome.ParticipantsWe included reviews that included children ages 6 yearsand younger. A review did not have to include only children 6 years and younger; we included reviews with atleast one primary study with our population of interest.We did not employ any limitations regarding gender, socioeconomic status, or specific child health conditions.InterventionWe included systematic reviews that focused on or included garden-based interventions. As garden-based interventions are inherently complex to define due to variationin type and setting, we included any intervention that engaged children in active learning about nutrition, food systems, agriculture, or environmental health throughconnections with outside fruit or vegetable gardens orfarms, raised garden beds, greenhouses, container gardens,microfarms, or other alternative gardening methods [37].We also included farm-to-preschool and farm-to-child careprograms, which often link young children with fresh produce from local farms.Types of studiesWe included peer-reviewed systematic reviews, with orwithout meta-analyses, published January 1990 throughAugust 2019 [41]. We used the following definition ofsystematic review, which aligns with the definition of asystematic review provided in the PRISMA-P 2015 statement: a review which (a) has an explicit set of aims; (b)employs a reproducible methodology, including a systematic search strategy and selection of studies; and (c)systematically presents and synthesis characteristics ofincluded studies [42]. We excluded reviews that failed tomeet this definition. We included systematic reviews ofstudies that had randomized, quasi-randomized, andnon-randomized designs. We excluded reviews that included qualitative studies only.Study screening and selectionWe imported the associated Endnote X9 (Clarivate Analytics) library for each database search directly into Covidence. Citations were automatically de-duplicated aspart of the import process. Two teams, each consisting
Skelton et al. International Journal of Behavioral Nutrition and Physical Activityof two reviewers, independently screened titles and abstracts. During this iterative screening process, Covidenceautomatically filtered citations into one of three lists, ‘Irrelevant”, “Resolve Conflicts”, and “Full Text Review”. Weresolved disagreements between reviewers using consensus; no third reviewer was necessary. If a review teamcould not make an inclusion decision during the title andabstract screening phase, the article moved forward to fulltext review. After title and abstract screening, we gatheredcitations in their full-text, PDF form for full-text review.The same two teams of reviewers independently completed full-text screening, during which both reviewershad to agree on a final inclusion or exclusion decision.Data extractionThree reviewers across two teams independently extracted data from included articles directly into a customized data extraction form within Covidence. Foreach included article, we extracted the following: citationdetails, aims or objectives, review type, eligibility criteria(e.g., population, setting, intervention type, study design),search strategy and results (e.g., number of databasessearched, date range, inclusion of gray literature, numberof included studies), relevant child-level healthFig. 1 PRISMA flow diagram(2020) 17:121Page 4 of 19outcomes, and funding source. We also extracted data atthe primary study level for eligible studies, which included citation details, population, setting, interventiontype and design, results, limitations, and conclusions toenable us to account for primary study overlap [36]. Wecontacted corresponding authors for missing information and clarification, if needed.Quality appraisalThree reviewers split into two teams independently performed quality assessment of included reviews via theAMSTAR 2 (A Measurement Tool to Assess SystematicReviews) questionnaire [43]. The AMSTAR 2 is a 16item validated quality assessment tool that allows for inclusion of both randomized and observational studiesand as such, is not intended to be scored [44]. Reviewersresolved any discrepancies through discussion and consensus on appraisal criteria.ResultsOut of 9452 titles and abstracts screened for inclusion,20 reviews were eligible. However, 4 reviews were previous versions of a living systematic review [45–48] andtherefore, not included in data extraction. Fig. 1
Skelton et al. International Journal of Behavioral Nutrition and Physical Activitydescribes results of the systematic search and study selection process, in accordance with PRISMA reportingguidelines [38]. See Additional file 2 for the full list ofexcluded studies.(2020) 17:121Page 5 of 19the Cochrane Risk of Bias tool [58]. The remaining 6 reviews did not perform any quality assessment of originalstudies [27, 49, 50, 52, 54, 56].Quality of included reviewsDescription of included reviewsTable 1 details characteristics of the 16 included Systematic reviews [27, 30, 31, 48–60], including aim, topicarea, interventions and populations included, databasessearched, and funding source. Included reviews werepublished in English between 2004 and 2019. Five reviews included gray literature as part of their searchstrategy [31, 51, 52, 57, 59]. Five reviews focused ongarden-based interventions and therefore, included onlygarden-based interventions [27, 30, 31, 54, 56]. Other reviews focused on improving nutrition status or healthyeating and included an array of agricultural, obesity prevention, nutrition education, and multi-component interventions. Similarly, some reviews examined onespecific outcome (e.g., vegetable intake, physical activity)[49, 50], whereas others examined a number of outcomes (e.g., obesogenic behaviors) [60]. Three reviewsincluded interventions that assessed vegetable-relatedoutcomes only (e.g., intake, preferences, purchasing,provision) [49, 55, 59]; an additional 3 reviews includedonly interventions that measured fruit or vegetable outcomes [30, 48, 56]. Although only 5 reviews conductedformal meta-analysis [48, 50, 56–59], several reviews reported an inability to do so due to variation in study design and measures [27, 60], heterogeneity [55], and lackof sufficient data [58].The level of scientific evidence presented in reviewsvaried, with some reviews finding no significant association between garden-based interventions and healthoutcomes, and other reviews reporting only positive outcomes. Across reviews, multi-component and multisetting interventions appeared to be most effective [30,48, 59, 60]. Of reviews that examined agricultural interventions, garden-based interventions [27, 30, 31, 54, 56]seemed to be more effective in improving nutritionrelated indicators than other interventions, such as onlynutrition education, agriculture technology, or livestockproduction.Reviews included a total of 465 primary studies. Thenumber of primary studies included in reviews that metour inclusion criteria ranged from 1 [50] to 6 [52] acrossreviews. Most reviews (n 10) assessed the quality oforiginal studies via an array of tools, including the Effective Public Health Practice Project Quality Assessment Tool [30, 31, 55, 59], Stetler’s Level of QuantitativeEvidence [60], an adapted version of Critical AppraisalSkills Programme for RCTs [53], and the Cochrane Riskof Bias tool [48]. Two reviews developed their own rating system to appraise quality [51, 57] and one adaptedHodder et al. 2019 was the highest quality review, fulfilling 15 out of 16 of the AMSTAR 2 elements [48]. Incontrast, Beets et al. fulfilled only one and partially fulfilled two AMSTAR 2 appraisal elements [50]. Most reviews included the PICO elements in their inclusioncriteria, either explicitly or implicitly, whereas only 3 reviews explicitly stated they developed an a priori protocol [31, 48, 59]. A small number of reviews (n 5)investigated publication bias and discussed its impact onreview results [31, 48, 56, 59]. Of included reviews, Hodder et al. 2019 was the only review that reported onfunding of included studies [48]; the remaining reviewsdid not report on funding for primary studies. Table 2provides comprehensive results of the AMSTAR 2 quality appraisal.OverlapWe used a validated measure, the corrected covered area(CCA), to calculate the extent of overlap at the primarystudy level across included reviews [61]. We calculatedthe CCA by dividing the frequency of repeated occurrences of primary studies across reviews by the productof index publications and reviews, reduced by the totalnumber of primary studies. The CCA was estimated tobe 4.7, representing only slight overlap amongst includedreviews [61]. The citation matrix used for calculatingoverlap is available in Additional file 3. NamenekBrouwer et al. was the article included in the most number of reviews (n 7) [14].Garden-based interventionsTable 3 describes characteristics of garden-based interventions, including setting, country, relevant findings,and conclusions. Across included reviews, 24 unique primary garden-based intervention studies met inclusioncriteria [14, 24, 25, 62–82] and were published between1991 [70] and 2017 [25]. Most garden-based interventions (n 15) were implemented in the home [24, 25,64, 67–71, 73–77, 82] and 8 were conducted in school,afterschool, or early care and education settings [14, 63,65, 66, 78–81]. Only one community garden-based intervention included our age group of interest [62].Effective components of garden-based interventionsReviews discussed a number of components of gardenbased interventions, including hands-on gardening,utilization of produce from garden (e.g., consumption,taste-testing, sale), staff training, nutrition education andcooking components. Amongst reviews, there was
AimTo systematically review theliterature to identify allpublished interventionsaiming to increase vegetableconsumptionTo provide a systematicreview of published researchexamining after-schoolprograms targeting youthphysical activityTo collate findings on schoolgarden interventions thatinclude measures of academicperformance and fruit andvegetable consumptionTo critically review theliterature concerningeffectiveness of agricultureinterventions in improvinghousehold nutrition statusTo estimate the effects ofundernutrition on childhooddeath and disability outcomesTo identify and evaluate thestrength of evidence frominterventions that assessedthe impact of agriculturalinterventions on nutritionaloutcomesTo review school gardenbased programs targetingdietary intake and relatedbehaviors in children; toidentify strategies andcomponents employed bygarden-based programsTo identify interventioncharacteristics and behaviorchange techniques associatedwith increasing children’svegetable consumptionTo assess the effectiveness,cost effectiveness andadverse events ofStudyAppleton et al. [49]Beets et al. [50]Berezowitz et al. [27]Berti et al. [51]Bhutta et al. [52]Bird et al. [53]Davis et al. [54]Hendrie et al. [55]Hodder et al. [48]InterventionAny pre/post schoolgarden interventionSchool gardens andhealth outcomesChildren 18yRCTs, cluster-RCTs, andcross-over trialsPubMed, PsycINFO and CABabstracts; 2004 to June 2014CENTRAL, MEDLINE, Embase,CINAHL, PsycINFO, ProQuest,WHO Clinical Trials Registry,Children 5yMedline and Embase, andgray literatureWeb of Science, Scopus,PubMed, CAB Abstracts,AGRIS, and gray literature;Jan. 2012 to Nov. 2017Children 2-12yChildren of schoolagePakistan, India,Afghanistan, Nepal,or BangladeshFunding SourceCenters for DiseaseControl & Prevention’sCommunity TransformationGrantNot reportedEuropean Union’sResearch and Innovation7th FrameworkNot reportedHorticulture InnovationAustralia Limited, CSIRONo fundingLeveraging Agriculture forNutrition in South AsiaResearch ConsortiumWorld Bank; InternationalCentre for Diarrheal DiseaseResearch, BangladeshMedline, Current Contents,Canadian InternationalBiosis Previews, PASCAL, AGRIS, Development Agencyand gray literature, 1985 toNov. 2001CABI, Web of Knowledge, Webof Science, PubMed, EducationFull Text, ERIC, and PsycINFO,up to May 2013PubMed, ScienceDirect &EBSCOhost; 1980 to Feb. 2008Children andPubMed, Current Contents,households inHelen Keller International,developing countries Medline, Biosis Previews,AGRIS, PASCAL & grayliterature; 1995 to Nov. 2001No restrictionsDatabases SearchedPubMed, PsycINFO, Medline& gray literature; up to Apr.28, 2015(2020) 17:121Fruit and vegetableconsumptionAny interventionevaluating effectivenessQuasi-experimental, RCTNutrition-sensitiveagricultureDietary diversification via Any agriculturalagricultural productioninterventionVegetable intakePopulationAnyAny garden interventionK-12th graders inlasting at least one month western culturesRCT or quasi-experimentalAnyAgriculture interventions Any agricultureand nutritioninterventionSchool gardens andacademic performanceAfterschool programsand physical activityVegetable intakeTopic AreaTable 1 Characteristics of included systematic reviewsSkelton et al. International Journal of Behavioral Nutrition and Physical ActivityPage 6 of 19
AimTo review published literatureHealthy eating inon healthy eating interventions preschoolsin day care facilities and analyzeeffectiveness of differentstrategies in relation to theirinfluence on children’s foodchoiceTo investigate effectiveness ofVegetable intake ininterventions to increase young young childrenchildren’s vegetable intakethrough a comprehensivesearch that includes a varietyof study designs and settingsTo conduct a robust, mixedmethods systematic reviewof the health and well-beingimpacts of school gardeningTo identify effectiveness ofgardening interventions toimprove fruit and vegetableintake among childrenTo determine effectivenessof obesogenic behavioralinterventions in childcarecenters across socialecological levels anddescribe strategies utilizedMikkelsen et al. [58]Nekitsing et al. [59]Ohly et al. [31]Savoie-Roskos et al.[30]Sisson et al. [60]Any nutrition educationprogramInterventionObesogenic behaviorinterventions in childcareGarden-basedinterventions and fruitand vegetable intakeHealth and well-beingimpacts of schoolgardensChildren 3-6yChildren in low- ormiddle-incomecountriesK-8th graders in theUSPopulationChildren 2-15y indeveloped countriesChildren 18y inOECD countriesAny intervention targeting Children 3-5y inobesity, physical activity,child care centersor screen timeAny community, school,or after-school gardeninterventionAny garden interventionin a school settingAny intervention aimingChildren 2–5yto increase child vegetableintakeObesity preventioninterventions, pre/postdesign or strongerAgricultural interventions Longitudinal projectand nutritional statuscontrols and randomizedfield trials that aim toimprove nutrition statusTo inform policymakers onthe effectiveness ofinterventions and suggestwhich designs, methods,and metrics should beused in future researchMasset et al. [57]Topic AreaTo examine the efficacy ofGarden-based programsgarden programs for increasing and child nutritionchildren’s nutrition knowledge,fruit and vegetable preference,and fruit and vegetableconsumptioninterventions designed toincrease the consumptionof fruit or vegetables orboth among children 5 yearsLangellotto et al. [56]StudyTable 1 Characteristics of included systematic reviews (Continued)PubMed, PsycINFO, Ovid;up to Jan. 2016PubMed, Web of Science,CINAHL, Scopus; 2005 toOct. 2015MEDLINE, Embase, PsycINFO,HMIC, SPP, AEI, BEI, ASSIA,BNI, ERIC, AMED, CINAHL,and gray literature; up toMay 2015Scopus, Medline, PsycINFO,CAB Abstracts, Embase,CINAHL, ERIC, CENTRAL,ProQuest, PubMed, & Webof Science, and gray literature;2005 to Jan 2016PubMed, Scopus, Web ofScience & CINAHL; 1980to 2014Econlit, IBSS, PubMed, andWeb of Science, AGRIS, &gray literature; 1990 toSept. 2010Google Scholar, PubMed,Web of Knowledge andAmerican Society ofHorticultural Sciencearchives, and gray literatureClinicaltrials.gov, GoogleScholar; up to Aug. 25, 2019Databases SearchedNo fundingNo fundingEuropean Centre forEnvironment and HumanHealthWhite Rose Social SciencesEconomic and SocialResearch CouncilCollaborative AwardNot reportedUnited Kingdom Departmentfor International DevelopmentNot reportedFunding SourceSkelton et al. International Journal of Behavioral Nutrition and Physical Activity(2020) 17:121Page 7 of 19
YesYesNoNoPartial YesPartial YesYesYesPartial YesNoYesYesYesYesYesBerti et al 2004 [51]Bhutta et al2008 [52]Bird et al 2019 [53]Davis et al 2015 [54]Hendrie et al2017 [55]Hodder et al2018 [45]Langellotto et al2012Massett et al 2012Mikkelsen et al2014 [58]Netkitsing et al 2018Ohly et al 2016 [31]Savoie-Roskos2017 [30]Sisson et al2016 [60]NoNoNoNoNoNoYesNoNoNoNoNoNoYesNoBerezowitz et al2015 [27]NoBeets et al 2009 [50]Partial YesAppleton et al2016 artialYesPartialYesNoNoPICOA priori Study Searchcomponents Protocol Design StrategyTable 2 AMSTAR 2 appraisalNoNoYesNoNoPartialYesNoYesNoNo
summer camps. We included garden-based interventions that focused on gardening interventions only, as well as multi-component interventions that included gardening. Outcomes We included reviews with at least one of the following child-level health outcomes of interest: nutrition-related behaviors (e.g., co
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